Pulsed-field ablation of atrial fibrillation in octogenarians: safety profile and two-year outcomes

Introduction

In the Czech Republic, the majority of catheter ablation procedures for atrial fibrillation (AF) are currently performed using pulsed-field (PF) ablation. Management of older AF patients is often challenging; however, this age group is increasingly being considered for invasive treatment.

Objectives and Methods

The objective was to evaluate procedural characteristics, safety, and efficacy of PF ablation in patients older than 80 years. The analysis included patients with paroxysmal or persistent AF who underwent ablation between 2023 and 2024 using multispline catheters. In paroxysmal AF, pulmonary vein isolation was performed; in persistent AF, additional box and linear lesions at the mitral and cavotricuspid isthmus were added. All procedures were performed under general anesthesia. Seven-day ECG Holters were performed every 6 months during follow-up.

Results

During the study period, 1,179 patients underwent PF ablation, of whom 61 (5%) were 80–89 years old (23 males, 37,7%). Mean left atrial diameter was 46±5 mm and left ventricular ejection fraction was 64±8%. Persistent AF predominated (49 patients, 78%). Mean procedure duration was 49±12 minutes (25–85), mean fluoroscopy time 7.6±3.2 minutes (dose 4302±3961 mGy·cm²), and the mean number of PF applications was 74±18 (27–114).

Three minor complications (groin hematomas) were recorded, all managed conservatively. Two patients experienced transient coronary vasospasm with ST-segment elevation on surface ECG, once accompanied by complete AV block. After medication, rapid stabilization occurred and both were discharged the next day without sequelae. All procedures were completed with successful acute achievement of target lesions in 100% of patients, and 52 patients (85%) were non-inducible at the end of the procedure using repetitive incremental atrial pacing up to cycle length of 200 ms from the proximal coronary sinus and left atrial appendage.

Standard six-month follow-up was available for all patients. For the 2023 cohort, two-year follow-up was available, and for the 2024 cohort, one-year follow-up as well. Freedom from any supraventricular arrhythmia recurrence without antiarrhythmic drugs was observed in 51 patients (84%), while 58 patients (95%) maintained sinus rhythm on previously ineffective antiarrhythmic therapy.

Conclusion

PFA for AF is safe and highly effective in carefully selected patients aged over 80 years. Excellent results are evident at six months, and longer-term follow-up further supports durability of the achieved effect. Our data suggest that advanced age alone should not be a reason to withhold catheter-based treatment using PF energy.